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Leukocythemia is a disease of the blood which usually runs a chronic course and is associated with changes in the spleen, lymph glands or bone marrow respectively or unitedly. The distinctive history of the disease dates back probably forty years, when Dr. Hughes Bennett described a case. Virchow about the same time noted the same group of clinical symptoms, and later Mosler showed that one form was referable to changes in the spleen, another to changes in the lymph glands and a third to changes in the bone marrow. This disease is called splenic, lymphatic myelogenic or splenomyelogenic according to the organ or group of organs involved. Mixed forms are of the most frequent occurrence. Authors differ much as regards frequency, but it probably occurs in about one out of 10,000 cases of sickness.

Ætiologi:- Neither race nor climate has any traceable influence on the disease. Age is an important factor, the great majority of cases occurring between the ages of 20 and 50. It is rare in youth and old age but may occur at any time.

Males are much more frequently affected than females the proportion being about 2 to 1. Osler reports 17 cases, II in males and 6 in females. Birch-Hirschfield states that out of 200 cases collected, 135 were in males. Of the four cases I have seen two were males. When in females it usually appears between 35 and 40. Malaria or a history of residence in a malarial district is of very frequent occurrence in tracing the cause. Twenty-five per cent of the cases recorded by Gowers give a malarial history. Blows over the spleen may be the direct causal factor. Any incident which produces a great impression on the nervous system may lead to its development. General unhealthful surroundings, depressing mental emotions and inanition predispose to leukemia as they do to other diseases.

Leukemia is not confined to man, but occurs in the lower animals, dogs, cats and guinea pigs, and only recently experimenters found in the organs of a dog that had died of leukemia a diplococcus which when injected into mice produced typical leukemia. The bacteriological cause of the disease, if it originates from such cause is not determined.

Morbid Anatomy and Pathology.—The anatomical characteristics of leukemia include changes in nearly all the organs of the body, particularly in the spleen, lymph glands, bone marrow and blood, with subsequent changes in the liver, kidneys and other organs. The spleen is always enlarged and weighs from one to eighteen pounds. The enlargement is uniform, the shape being well preserved and the surface smooth. On cut section the surface is greyish red or brownish red. The malphigian bodies may be enlarged and appear as small growths, or occasionally they are decreased in size. Microscopically there is an increase of connective tissue and an absence of red blood corpuscles. A brownish pigment in the form of granules is seen in the framework of the connective tissue or in the cells.

The lymphatic glands are early affected and in the lymphatic variety constitute many distinct tumors in the cervical, axillary, inguinal and mesenteric regions. They are not usually in bunches as in pseudo leukemia, but are alone, movable and soft and vary considerably in size during the course of the disease. In one of my cases there were several hundred of these enlarged glands distinctly palpable. The tonsils and lymph follicles of the tongue may be enlarged. A histological examination shows a general increase in the cellular elements. Hemorrhagic points are often seen.

The bone marrow may be whitish or dark brown in color, and pus like marrow with dark brown may be found side by side in the same bone. Microscopically, lymphoid cells and nucleated red blood cells are present in all stages of development. Mono and polynuclear leucocytes are also present. The capillaries and smaller vessels of the liver, pancreas and kidneys may be filled with leucocytes and no red cells be seen. The liver cells show degenerative changes. The heart and lungs and other organs of the body may show pathological changes. The blood is the most important tissue from a clinical standpoint and a diagnosis of leukemia can only be made

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17./2 after a careful examination of it. In color it is usually pale, the alkalinity is diminished and the fibrin increased. Corresponding to the two important clinical types, the splenic-myelogenous and the lymphatic, we have two distinct blood conditions. In the first or splenic myelogenous the nucleated red cells are very numerous, even in the absence of anæmia. The diminution in red cells is very moderate, being about 3,120,000 per c. m. The hæmoglobin is diminished.

The average number of white cells is 438,000 per c. m. .Cases are recorded where the white cells outnumbered the red. The average is about 1 to 7. In one of my cases the first count gave i to 8. In another 1 to 22. In a fresh specimen it is noticed that the white cells are not amoeboid, a point in distinguishing this from a leucocytosis. This is due to the fact that the myelocytes which form so large a proportion of the leucocytes do not possess the faculty of amæboid motion. The distinctive blood characteristic of this form of leukemia is the enormous increase in the myelocytes. In lymphatic leukemia the red cells are more decreased, on an average being about 2,730,000, and nucleated red cells are a rarity.

There is oligochromemia.

The average number of leucocytes is about 141,000 per c. m., and a differential count shows about 90 per cent lymphocytes. Only by a blood count 'can we distinguish lymphatic leukemia from pseudo leukemia or Hodgkins' disease, for the clinical picture may be very similar, but the blood in Hodgkins is normal, or shows a moderate leucocytosis, and the diseases are readily differentiated in this way. Transitions from Hodgkins to true leukemia may occur.

Symptoms.-In splenic myelogenous leukemia the onset is usually slow, and the symptoms may not differ materially from anæmia. There is languor, dizziness, fainting spells, with palpitation, pains in the splenic region, with a slowly increasing tumor. Hæmorrhages may be present, epistaxis, hematemesis, hematuria, enterorrhagia, and if these occur increasing pallor.

The pulse is usually rapid, soft and compressible. A hæmic murmur may be heard at the apex of the heart.

The bowels are usually constipated, but diarrhea may alternate with constipation. As the disease progresses syncopal attacks become more frequent, exhausting hemorrhages occur and the patient dies. Occasionally there is a period of seeming recovery, but after a varying time the improvement ceases and the patient grows rapidly worse. Lymphatic leukemia may run its course with few active symptoms, the patient's attention being called to his condition only by the increase in the glands. Hemorrhages occur in this variety also, and we may have all or few of the symptoms I have enumerated. Where the mixed myelogenous variety is present there is pain on percussion over the sternum or long bones, and there may be swelling and irregularity.

Complications.-Fatal hemorrhages may occur at any time. Ascites, 'general ædema, septicæmia, pyæmia, severe diarrhea are among the more frequent complications.

Prognosis. This is unfavorable.

The usual time in the splenic or spleno-myelogenic form is three to five years, while in the lymphatic the usual period of existence is three to eight or ten months.

Intercurrent affections often cause death.

Treatment. We have no remedies which are curative. After a diagnosis is established the most we can do is to relieve distressing symptoms and prolong life. The iemedies which have been used, and which have given us the best results, are arsenic, ferrum, bone marrow or preparations of like character.

I have in the past two years seen four cases of leukemia, one of which was a case of true lymphatic leukemia. No direct causal factor could be traced in this case. It is probable, however, from the fact that he had a nervous disorder sometime previous, that this may have been the cause. A history of this case is given herewith with the picture of the patient, showing enlarged glands in the inguinal and axillary regions, and also a chart of the blood, which shows the enormous increase in the leucocytes, which, presenting the characteristics shown here, are known as lymphocytes.

5—30—98—Anamnesis.-Family history: Father dead; drowned at 50: mother died at 90; one brother living; one died in infancy; one sister living. “No history of any chronic disease.”

. Personal history.—Married 22 years; six children; one child died at 7.

Occupation.-Carpenter.

Habits regular; no tobacco; no alcoholics for three years; never used much before that time.

Previous illness.—Diseases of childhood denied; pneumonia fifteen years ago; says he had hemiplegia at this time, affecting right side of face and arm principally. This condition gradually improved, until at present it cannot be noticed.

Venereal denied ; measles last August.
Present illness. After recovering from the measles he noticed

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